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� rbC CG r►�e �- <br /> WELL/PUMP PERMIT how <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> Y NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> • JOB ADDRESS 13883 S AUSTIN RD cmytzIP MANTECA 95336 <br /> D <br /> CROSS STREET FRENCH CAMP RD AP mbf 0M/ Ifl 5 PARCEL SIZE LAND USE APPLICATION# m <br /> y <br /> OWNER NAME WAYNE BUTNAM PHONE 679.2749 <br /> OWNER ADDRESS 13883 S AUSTIN RDIIZ4-& Lf'1mTY/STATEIZIP MANTECA CA 95336 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON CA 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pdvate -1 Irrigation/Agricultural n Industrial L Water Quality Monitoring n Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner; Water 5YStern Name contad Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well ❑Well Alteration/Modification a Other <br /> Monitoring Well(s) #of wells a Soil Boring(s) #of borings I i Geotechnical #of bodngs <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal _1 Cross-Connection Repair <br /> New Pum X Pump Replacement n Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger n Cable Tool i Push Point F Other <br /> Proposed Well Depth It Excavation in diameter _1 Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel n Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft 1 i Neat Cement(94 Ib bag/5-10 gal water) a Sand Cement sack mixf7 gal water <br /> - Bentonite(20%solids) 1 1 Other <br /> Grout Placement Method I Pumped L Free Fall n Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By i_ Driller a Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width It Length it Thick in - Christy Box -]Stove Pipe <br /> PUMP XSubmersibler Turbine II Other HP__J_ PumpSet___6O_ft Standing Water Level__,V_ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQU OUNTY ORIaINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR NT A ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO ERS COMPENS ON LA <br /> I U 2 H UR ANCE TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95;-7697 (` <br /> SIGNED TITLE DATE (� / <br /> jk. <br /> N <br /> E <br /> SIf 1.111. <br /> INN <br /> PAYM <br /> RECEI IFF <br /> MAY 3 <br /> SAN JOAQU <br /> EWRON AE 4L <br /> HEALTN DF A <br /> VJJD#CARTMENT U E N L Y ��/� <br /> Application Accepted By Date Areae/ /.' Employee <br /> Grout Inspection By Date 1 I SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inpq4tion By Date Constructed We De th <br /> CO MENTS p L QH/YIC✓ <br /> �� e--1­4 e jk* <br /> PE ISC I Received Amount Date Perm!V Invoice# Well ID# <br /> Codes Info B as Remitted Service Re uest# <br /> v a -70V Wr00'5q <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />